Letters to the Editor
Audit on diabetes care in a secondary hospital in South India Sir, There is a notable increase in the incidence of diabetes mellitus nationally. WHO states that effective management of diabetes is imperative at the primary care level to improve health outcomes.[1] In India, the network of primary health care system is not always effective, efficient and accountable. One of the methods of improving efficiency and accountability is conducting regular clinical audits. UK’s National Institute for Health and Clinical Excellence defines clinical audit as: “It is a process of improving quality of patient care and outcomes by reviewing care against specific criteria and then reviewing the change”.[2] With the aim of improving care of diabetes in our health center, a clinical audit on diabetes care was carried out between October 2011 and June 2012 with the objective of evaluating the effectiveness of audit in improving practice in diabetes care in a secondary health setting. This audit was conducted in an urban health center primarily managed by qualified family physicians and community medicine doctors that provides primary and secondary level health services to a population of 200,000. We used nine process indicators suggested by ICMR for monitoring diabetic patients in our audit process [Table 1].[3] The target level for the non-laboratory indicators was agreed at 80% and for laboratory indicators at 50% by the team. The outcome was assessed by the level of glycemic control, LDL level, compliance with appointment and the presence of complications. A total of 200 charts of patients with type 2 DM were reviewed initially and audit cycle was completed 6 months after the introduction of practice changes. Diabetic flow charts for annual follow-up were introduced and sessions on diabetic management held. Annual retinal exam, foot exam and creatinine were to be done on all patients. HbA1C and lipid testing were restricted to patients with controlled sugars based on glucometer values. SPSS version 17 was used to perform all statistical analysis. Oral hypoglycemic agents were the main stay of treatment [Table 2]. After clinical audit, performance on process indicators, glycemic control based on capillary sugars and compliance improved significantly [Figure 1 and Table 3]. The level of glycemic control worsened in those with a longer duration of diabetes [Figure 2].
1130
The overall quality of diabetic care in the health center was poor prior to the audit. There was lack of adherence to any standard guideline for longitudinal care and no system for monitoring complications. There are no diabetic audit data available nationally for comparison. However, this is comparable to the poor documentation noted in Cost of Diabetes in India (CODI) study among general practitioners.[4] This is in contrast to the data available from 5 OECD (Organization for Economic Co-operation and Development) countries where audit and registry for diabetes care has allowed for comparison and improved health outcome.[5] Table 1: Indicators of diabetes care Process assessment Fasting and post-prandial sugars recorded at each visit (3 monthly) Blood pressure recorded at each visit (3 monthly) Annual BMI and weight recorded at each visit (3 monthly) Life counseling at each visit Annual HbA1C Annual lipid profile Annual screening for nephropathy Annual eye exam Annual foot exam Outcomes of diabetes care Glycemic control LDL control Degree of compliance with appointment Presence of complications BMI: Body mass index, HbA1C: Glycosylated hemoglobin, LDL: Low density lipoprotein
Table 2: Baseline characteristics Variables Gender Male Female Age (years) 30-39 40-49 50-59 60 years Not documented Smoking status Current smoker Ex-smoker Non-smoker Not-documented Duration of diabetes (years) 2 2.1-5 5.1-10 10 Not documented Treatment received for diabetes Lifestyle modifications only OHA OHA and insulin Insulin only
Frequency (%) 57 (28.5) 143 (71.5) 5 (2.5) 39 (19.5) 69 (34.5) 86 (43.0) 1 (0.5) 6 (3) 28 (14) 164 (82) 2 (1) 33 (16.5) 58 (29) 71 (35.5) 37 (18.5) 1 (0.5) 3 (1.5) 165 (82.5) 31 (15.5) 1 (0.5)
OHA: Oral hypoglycemic agents
Indian Journal of Endocrinology and Metabolism / Nov-Dec 2013 / Vol 17 | Issue 6
Letters to the Editor 120% 100% 100% 97%
100%
97%
94.50% 88%
83%
80%
75%
80%
66.50% 52%
60%
46%
43% 40%
Pre-Audit
28.50% 20%
15.50%
20%
19.50%
3%
Post-Audit
1% 1.50%
nu
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Ey e
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es pr
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0%
Figure 1: Process measures of diabetic care
Fasting sugar in mg/dl
>140
Table 3: Clinical outcomes of diabetes care
120 - 140
Variables
Audit on diabetes care in a secondary hospital in South India Sir, There is a notable increase in the incidence of diabetes mellitus nationally. WHO states that effective management of diabetes is imperative at the primary care level to improve health outcomes.[1] In India, the network of primary health care system is not always effective, efficient and accountable. One of the methods of improving efficiency and accountability is conducting regular clinical audits. UK’s National Institute for Health and Clinical Excellence defines clinical audit as: “It is a process of improving quality of patient care and outcomes by reviewing care against specific criteria and then reviewing the change”.[2] With the aim of improving care of diabetes in our health center, a clinical audit on diabetes care was carried out between October 2011 and June 2012 with the objective of evaluating the effectiveness of audit in improving practice in diabetes care in a secondary health setting. This audit was conducted in an urban health center primarily managed by qualified family physicians and community medicine doctors that provides primary and secondary level health services to a population of 200,000. We used nine process indicators suggested by ICMR for monitoring diabetic patients in our audit process [Table 1].[3] The target level for the non-laboratory indicators was agreed at 80% and for laboratory indicators at 50% by the team. The outcome was assessed by the level of glycemic control, LDL level, compliance with appointment and the presence of complications. A total of 200 charts of patients with type 2 DM were reviewed initially and audit cycle was completed 6 months after the introduction of practice changes. Diabetic flow charts for annual follow-up were introduced and sessions on diabetic management held. Annual retinal exam, foot exam and creatinine were to be done on all patients. HbA1C and lipid testing were restricted to patients with controlled sugars based on glucometer values. SPSS version 17 was used to perform all statistical analysis. Oral hypoglycemic agents were the main stay of treatment [Table 2]. After clinical audit, performance on process indicators, glycemic control based on capillary sugars and compliance improved significantly [Figure 1 and Table 3]. The level of glycemic control worsened in those with a longer duration of diabetes [Figure 2].
1130
The overall quality of diabetic care in the health center was poor prior to the audit. There was lack of adherence to any standard guideline for longitudinal care and no system for monitoring complications. There are no diabetic audit data available nationally for comparison. However, this is comparable to the poor documentation noted in Cost of Diabetes in India (CODI) study among general practitioners.[4] This is in contrast to the data available from 5 OECD (Organization for Economic Co-operation and Development) countries where audit and registry for diabetes care has allowed for comparison and improved health outcome.[5] Table 1: Indicators of diabetes care Process assessment Fasting and post-prandial sugars recorded at each visit (3 monthly) Blood pressure recorded at each visit (3 monthly) Annual BMI and weight recorded at each visit (3 monthly) Life counseling at each visit Annual HbA1C Annual lipid profile Annual screening for nephropathy Annual eye exam Annual foot exam Outcomes of diabetes care Glycemic control LDL control Degree of compliance with appointment Presence of complications BMI: Body mass index, HbA1C: Glycosylated hemoglobin, LDL: Low density lipoprotein
Table 2: Baseline characteristics Variables Gender Male Female Age (years) 30-39 40-49 50-59 60 years Not documented Smoking status Current smoker Ex-smoker Non-smoker Not-documented Duration of diabetes (years) 2 2.1-5 5.1-10 10 Not documented Treatment received for diabetes Lifestyle modifications only OHA OHA and insulin Insulin only
Frequency (%) 57 (28.5) 143 (71.5) 5 (2.5) 39 (19.5) 69 (34.5) 86 (43.0) 1 (0.5) 6 (3) 28 (14) 164 (82) 2 (1) 33 (16.5) 58 (29) 71 (35.5) 37 (18.5) 1 (0.5) 3 (1.5) 165 (82.5) 31 (15.5) 1 (0.5)
OHA: Oral hypoglycemic agents
Indian Journal of Endocrinology and Metabolism / Nov-Dec 2013 / Vol 17 | Issue 6
Letters to the Editor 120% 100% 100% 97%
100%
97%
94.50% 88%
83%
80%
75%
80%
66.50% 52%
60%
46%
43% 40%
Pre-Audit
28.50% 20%
15.50%
20%
19.50%
3%
Post-Audit
1% 1.50%
nu
I
tie
BM
ria
e in Pr o
re C
Ey e
C
at in
ar
ar C
C
Fo
ot
el ns
ou
e
e
g lin
d pi Li
BA 1C H
es pr
od Bl o
Bl o
od
su
su
ga
r
re
0%
Figure 1: Process measures of diabetic care
Fasting sugar in mg/dl
>140
Table 3: Clinical outcomes of diabetes care
120 - 140
Variables
